Patients' subjective concepts about primary healthcare utilisation: the study protocol of a qualitative comparative study between Norway and Germany

Utilisation of supplementary prenatal screening and diagnostics in Germany: cross-sectional study using data from the KUNO Kids Health Study

BACKGROUND

Appropriate health system utilisation during pregnancy is fundamental for maintaining maternal and child's health. To study the use and determinants of supplementary prenatal screening and diagnostics in Germany this study provides comprehensive data.

METHODS

We obtained data from a recently established prospective German birth cohort study, the KUNO Kids Health Study. Analyses are based on Andersen's Behavioural Model of health system use, which distinguishes between predisposing (e.g. country of birth), enabling (e.g. health insurance) and need factors (e.g. at-risk pregnancy). We examined bi- and multivariate association with the use of supplementary prenatal screening and diagnostics using logistic regression.

RESULTS

The study has a sample size of 1886 participating mothers. One fifth of the mothers investigated did not use any supplementary prenatal screening or diagnostics. Notably, the chance of using supplementary prenatal screening and diagnostics more than doubled if the pregnant woman had a private health insurance (OR 2.336; 95% CI 1.527-3.573). Higher maternal age (OR 1.038; 95% CI 1.006-1.071) and environmental tobacco smoke exposure (OR 1.465 95% CI 1.071-2.004) increased the use of supplementary prenatal screening and diagnostics. However, regarding need factors only having an at-risk-pregnancy (OR 1.688; 95% CI 1.271-2.241) showed an independent association.

CONCLUSION

The important role of the type of health insurance and the relatively small influence of need factors was surprising. Especially with respect to equity in accessing health care, this needs further attention.

Patients' attitudes toward copayments as a steering tool-results from a qualitative study in Norway and Germany

BACKGROUND

Copayments are implemented in many health care systems. The effect of copayments differs between countries. Up to now, patients' attitudes regarding copayments are mainly unknown.

OBJECTIVES

Thus, the goal of our analysis was to explore adult patients' attitudes in Germany and Norway towards copayments as a steering tool.

METHODS

We conducted a qualitative comparative study. Episodic interviews were conducted with 40 patients in Germany and Norway. The interviews were analysed by thematic coding in the framework of grounded theory. All text segments related to copayments were analysed in depth for emerging topics and types.

RESULTS

We found three dimensions of patients' attitudes towards copayments: the perceived steering effect, the comprehensibility, and the assessment of copayments. The perceived steering effect consists of three types: having been influenced by copayments, not having experienced any influence and the experience of other persons to be influenced. The category comprehensibility describes that not all patients understand rules and regulations of copayments and its caps. The assessment of copayments consists of nine subcategories, three of which are rather negative and six of which are rather positive. In all three dimensions the patterns between the German and Norwegian sub-samples differ considerably.

CONCLUSIONS

The results of our study point at the importance of communicating clear rules for copayments which are easily comprehensible.

A sequential model for the structure of health care utilization

Traditional measurement models of health care utilization are not able to represent the complex structure of health care utilization. In this qualitative study, we, therefore, developed a new model to represent the health care utilization structure. In Norway and Germany, we conducted episodic interviews, participant observation and a concurrent context analysis. Data was analyzed by thematic coding in the framework of grounded theory. Consultations do very often not only have one single reason for encounter. They are usually not independent events but form part of consultation sequences. We could find structural differences between Norway and Germany regarding the flow of information between consultations and which providers are involved in health care in what way. This leads to a sequential model, in which health care utilization is seen as sequences of consultations. Such health care utilization sequences consist of nodes which are connected by edges. Nodes represent patient-provider contacts and edges depict the flow of information. Time and the level of health care providers are dimensions in the model. These sequences can be described by different measures and aggregated on population level. Thus, the sequential model can be further used in analyzing health care utilization quantitatively, e.g., by using routine data.

[Regulations of sickness certification as a factor for increased health care utilization in Germany]

BACKGROUND

In Germany, utilization of ambulatory health care is high compared to other countries. Classical models of health care utilization cannot sufficiently explain these differences. The aim of this study was to explore relevant factors which can explain the higher health care utilization in Germany. In this article, we focus on regulations regarding sickness certification as a potential factor.

METHODS

An explorative qualitative study design. We conducted episodic interviews with 20 patients in Germany and 20 patients in Norway and participant observation in four primary care practices each. Additionally, we conducted a context analysis of relevant health care system related factors which emerged during the study. Qualitative data analysis was done by thematic coding in the framework of grounded theory.

RESULTS

The need for a sickness certificate was an important reason for encounter in Germany, especially regarding minor illnesses. Sickness certification is a societal topic. GPs play a double role regarding sickness certification, both as the patients' advocate and as an expert witness for social security services. In Norway, longer periods of self-administered sickness certification and more differentiated possibilities of sickness certification have been introduced successfully.

CONCLUSION

Our results point to regulations regarding sickness certification as a relevant factor for higher health care utilization in Germany. In pilot studies, the effect of extended self-certification of sickness and part-time sickness certification should be further assessed.